1. The Field of the Invention
The present invention relates to systems and methods for facilitating the processing of health care insurance claims from an institutional health care provider. More particularly, the present invention relates to systems and methods for promptly delivering supporting documents to an insurance carrier or payer to facilitate processing of a health care insurance claim for services rendered by the institutional health care provider.
2. The Relevant Technology
Over the years, the delivery of health care services has shifted from individual physicians to large managed health maintenance organizations. This shift reflects the growing number of medical, dental, and pharmaceutical specialists in a complex variety of health care options and programs. This complexity and specialization have created large administrative systems that coordinate the delivery of health care between health care providers, administrators, patients, payers, and carriers.
Although beneficial in some respects, the administrative system has increased the complexity of claim processing through requiring numerous supporting documents to accompany a health care insurance claim. These supporting documents, such as laboratory reports, X-rays, physician notes, patient charts, discharge papers, etc, are typically need before processing of the health care insurance claim can occur. The need for such supporting documents increases health care cost while, at the same time, makes it difficult for health care providers to receive payment for services rendered.
The need for supporting documents accentuates the detrimental effect that large administrative systems have had on the payment of claims for health care services. In addition to receiving and reviewing tens of thousands of payment requests each day and tens of millions of requests a year, a single health management organization has to verify receipt of appropriate supporting documents for each health care insurance claim. The sheer volume of payment requests and supporting documents creates a backlog of unpaid claims.
In many situations, the time delay caused by the backlog is increased through incorrectly delivering hardcopies of the supporting documents to the carrier or payer. Consequently the institutional health care provider often receives a request for the supporting documents a few days or weeks after filing the insurance claim. To enable the carrier or payer to process the insurance claim, an employee of the institutional health care provider must collect the needed documents, obtain hardcopies of the documents, and mail the copies to the carrier. Due to the slow communication between the institutional health care provider and carrier, it is not uncommon for a time delay of weeks or months between performance of health care by the institutional health care provider and processing and/or adjudication of the claim.
Additionally, time delays occur due to the complexity and fluidity of the contractual obligations between parties, i.e., the institutional health care provider, patient, carrier or payer. Often, there are many different contractual arrangements between patients, payers or carriers, and health care providers. The amount that is authorized for payment may vary by the service or procedure, by the particular contractual arrangement with each health care provider, by the contractual arrangements between the carrier or payer and the patient regarding the allocation of payment for treatment, and by what is considered consistent with current medical practice. As these contractual relationships change, it is often necessary for carriers or payers to spend additional time reviewing and analyzing claims, further delaying the payment for services rendered by the institutional health care provider. This is particularly true when claims are submitted with clerical errors, in which case the claim will be disputed and may ultimately have to be resubmitted. This is also the case when the institutional health care provider forgets to provide the appropriate supporting documents that are sometimes required by a carrier or providers and allow the carrier or provider to adjudicate an insurance claim.
This delay in time is exacerbated when a claim is disputed. When a claim is disputed, it must be adjudicated to determine exactly which services are authorized and how much an institutional health care provider will be paid. Adjudicating a claim can take several weeks or months and may require multiple submissions of the same claim, with or without associated supporting documents. While a claim is being adjudicated, an institutional health care provider is left without funds for services that have already been rendered, and as a result, the institutional health care provider may suffer serious financial problems that are associated with cash flow realities.
During recent years, there has been an attempt to expedite the payment of health care services by automating the process for creating, reviewing, and adjudicating payment requests. For example, there currently exist claims processing systems whereby technicians at an institutional health care provider's office electronically create and submit medical insurance claims to a central processing system. The technicians input information identifying the physician, patient, medical service, carrier or payer, and other data with the medical insurance claim. The central processing system verifies that the physician, patient, and carrier or payer are participants in the claims processing systems. If so, the central processing system converts the medical insurance claim into the appropriate format of the specified carrier or payer, and the claim is then forwarded to the carrier or payer. Upon adjudication and approval of the insurance claims, the carrier or payer generates a check, which is delivered to the provider. In effect, such systems bypass the use of the mail for delivery of insurance claims and save overall time. Unfortunately, such systems do not eliminate the need to deliver needed supporting documents through the mail, thereby limiting the efficiency of the automated claim adjudication system.
Further, even using these automated systems, medical technicians at the health care provider's office are often unable to determine whether the claim, as it is submitted, is in condition for payment. In the event that the claim is not in condition for payment, the claim will undergo a protracted adjudication, which may include multiple resubmissions of the same claim, with or without associated supporting documents. For example, it has been found that a large number of insurance claims are submitted with information that is incomplete, incorrect, or that describes diagnoses and treatments that are not eligible for payment. Accordingly, these claims may be rejected for any of a large number of informalities, including clerical errors, patient ineligibility, indicia of fraud, etc. The institutional health care provider, however, is not made aware of the deficiencies of the submitted claims until a later date, potentially weeks afterwards, when the disposition of the insurance claim is communicated to the institutional health care provider. As a result, many claims are subject to multiple submission and adjudication cycles, as they are successively created, rejected, and amended. Each cycle may take several weeks or more. The resulting duplication of effort decreases the efficiency of the health care system and increases the time it takes to process a claim.
Studies have shown that some insurance claim submission systems reject up to 70% of claims on their first submission for including inaccurate or incorrect information or for other reasons. Many of the claims are eventually paid, but only after they have been revised in response to an initial rejection. Thus, while systems that permit electronic submission of insurance claims marginally decrease the time needed to receive payment by eliminating one or more days otherwise required to deliver claims by mail, they remain subject to many of the problems associated with conventional claims submission systems. For instance, existing systems are incapable of providing an effective manner of delivering copies of supporting documents to the carrier or payer to enable adjudication of the claim.
In view of the foregoing, there is a need in the art for providing institutional health care providers with a manner to deliver supporting documents with an insurance claim that enables a carrier to quickly and efficiently process the insurance claim. Further, it would be an advancement in the art to provide a claims payment system that would enable institutional health care providers to deliver a claim request, with associated supporting documents, quickly and efficiently to enable the institutional health care provider to receive payment for services rendered prior to the completion of a conventional claims adjudication process, particularly when the adjudication process is protracted due to claim informalities and administrative inefficiencies.